(Affix identification label here) Clozapine Titration Guide

URN: Pre Commencement

not a valid • Assess current smoking status
Adult Clozapine Titration Chart Family name:
• Review and document medical history
prescription unless • Provide and explain clozapine information to consumer and family/carer
Given name(s):
Facility / Service: ................................................................................... identifiers present • Complete local clozapine prescribing requirements
• Inform local authorities as required
Ward / Unit: ...................................................... Year: 20 ..................
Address:
• Provide pharmacist with blood test results and prescription
Clozapine Patient Number (CPN): ............................................ Date of birth: Sex:   M   F   I • Complete all locally required authorisations
First Prescriber to Print Patient Name and Check Label Correct: • Complete Clozapine Monitoring see page 1

.......................................................................................................................................................................................................
Blood Test Monitoring
If clozapine dose missed for 72 hours or less:
Clozapine Monitoring ♦ • Monitoring should continue as normal with no additional requirements
Results If clozapine dose missed for 72 hours but less than 4 weeks:
() if required

Date (day 7): Date (day 14): Date (day 21): Date (day 28): • During the first 18 weeks - monitor weekly for at least 6 weeks or for as long as necessary to achieve a total of 18 weeks
Investigations Baseline After 28 days monitoring. For example if therapy is interrupted:
/ / / / / / / /
»» a) after 15 weeks monitor with weekly blood tests for 6 weeks after clozapine is recommenced
Date »» b) after 9 weeks monitor with weekly blood tests for 9 weeks after clozapine is recommenced
completed Normal Abnormal Normal Abnormal Normal Abnormal Normal Abnormal Normal Abnormal
• Consumers on monthly monitoring - monitor weekly for 6 weeks then continue with monthly monitoring if no problems detected
Full Blood Count (FBC) If clozapine dose missed for 4 weeks:
• Monitoring should recommence as for a new consumer
White Blood Cell Then continue
(WBC) weekly first 18 Observation Procedure
weeks
Neutrophils Refer to hospital procedure. Where this is unavailable the following are suggested monitoring guidelines.
then monthly
For Initial Dose:
Eosinophils 1. Take temperature, pulse, respiration (TPR), and lying and standing blood pressure (BP) prior to administration of clozapine

Do Not Write in this binding margin

2. Administer clozapine as prescribed
Troponin Then at 3 3. Repeat observations: » Half hourly for 2 hours
months » 1 hourly for 4 hours
C-Reactive Protein then annually
(CRP) 4. If above observations are outside normal parameters, seek medical review
Electro Cardiograph
Subsequent Dose:
(ECG) Then continue 1. Twice daily - TPR and lying and standing BP
Liver Function Test
as per local safe 2. Take observations pre-dose, and 4–6 hours post-dose
and quality use Smoking:
(LFT)
of clozapine • If change in smoking status notify Medical Officer
Urea and Electrolytes procedure
(U&E)
Management of side effects associated with clozapine therapy ♦

ADULT Clozapine titration chart

Blood group Side effect Time course for onset Recommended actions
Plasma glucose - Then at 6 months Refer to Clozapine Blood Results Monitoring System table
Neutropenia / First 18 weeks (but may occur at any
fasting then 12 months on page 3. Admit to hospital if agranulocytosis is confirmed.
Agranulocytosis time)
Total cholesterol - Symptoms may include a sore throat or fever.
fasting Myocarditis - within 6–8 weeks of Cease clozapine. Admit to hospital if myocarditis or
Myocarditis /
Low Density starting cardiomyopathy is confirmed. May present with flu-like
Cardiomyopathy
Lipoprotein - fasting Then at 3 Cardiomyopathy - may occur at any time symptoms.
(LDL) months Potentially life threatening therefore effective treatment or
High Density then every 6 Constipation Usually persists prevention of constipation is essential. Recommend
Lipoprotein - fasting months
(HDL)
high-fibre diet. Use bulk forming laxatives and stimulants.
First few months Give smaller dose in the morning. Reduce dose if necessary -
Triglycerides - fasting Sedation
May persist, but usually wears off check plasma level.
Beta Human Chorionic First few months Manage according to severity of symptoms. See literature for
Hypersalivation
Gonadotropin - female + - As required Very troublesome at night pharmacological options.
(Beta HCG) Reduce dose or slow down rate of increase. Advise consumer
Hypotension First 4 weeks
Cardiac ECHO to slowly stand up from a lying or sitting position.
Then continue
as per local safe Hypertension First 4 weeks, but sometimes longer Increase dose slowly. Hypotensive therapy may be necessary.
Clozapine level and quality use Common in early stages. If persistent at rest and associated
of clozapine Tachycardia First 4 weeks, but sometimes persists with fever, hypotension or chest pain may indicate myocarditis.
Full physical exam procedure
Refer to cardiologist.
Weight gain Usually during the first year of treatment Ensure dietary counselling before weight gain occurs.
Height
m Give antipyretic, perform urgent FBC and cardiac enzymes.
Fever First 3 weeks
Weight Seek urgent medical review.
kg kg kg kg kg
Consider prophylactic valproate if on high dose or with high
Then continue Seizures May occur at any time
Waist plasma level.
cm cm monthly
May give anti-emetic. Avoid prochlorperazine and
BMI [weight (kg) /
height (m2)]
Nausea First 6 weeks metoclopramide if caused previous Extra Pyramidal Side
Effects. Consider Gastro Oesophageal Reflux Disease (GORD).
Smoking - cigarettes
As required Nocturnal Review dose schedule. Avoid fluids before bedtime. Seek
per day May occur at any time
enuresis Medical Review.
These are suggested guidelines only, refer to the treating psychiatrist for individual monitoring requirements. Check Auslab / Auscare for Normal and Abnormal test parameters.
This is not an exhaustive list of side effects. Please see product information for further advice.
♦ Modified from: Taylor D, Paton C, Kapur S. The Maudsley Prescribing Guidelines. 10th ed. London(UK):Informa Healthcare UK Ltd; 2009. ♦ Modified from: Taylor D, Paton C, Kapur S. The Maudsley Prescribing Guidelines. 10th ed. London(UK):Informa Healthcare UK Ltd; 2009.
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 © The State of Queensland (Queensland Health) 2011 Contact MSQ@health.qld.gov.au
(Affix identification label here) Family name: Given name(s): URN:

URN:
Clozapine Blood Results Monitoring System Recommended Action
not a valid
Adult Clozapine Titration Chart Family name: Green Range WBC greater than 3.5 x 10 /L
9
Continue clozapine therapy.
prescription unless and
Given name(s):
Facility / Service: ...................................................................................
identifiers present Neutrophils greater than 2.0 x 109/L
Amber Range WBC 3.0–3.5 x 109/L Continue clozapine therapy with twice-weekly
Ward / Unit: ...................................................... Year: 20 .................. Address:
or blood tests until return to ‘green’ range.
Clozapine Patient Number (CPN): ............................................ Date of birth: Sex:   M   F   I Neutrophils 1.5–2.0 x 109/L
First Prescriber to Print Patient Name and Check Label Correct: Red Range WBC less than 3.0 x 109/L Stop clozapine therapy immediately. Refer to
or clozapine protocols for management guidelines.
Attach ADR Sticker
Neutrophils less than 1.5 x 109/L
(See Medication Chart for details) ....................................................................................................................................................................................................... Modified from Clozapine Titration Protocols
Do not prescribe clozapine until approvals obtained consistent with local procedure ♥ Conduct weekly blood monitoring as per Clozapine Monitoring on page 1
Date Medication ♥ ♥ ♥ ♥
Clozapine Day 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 Day

Route Frequency
Prescriber to enter Date Date
Oral Morning individual doses. (day / month) (day / month)
Prescriber’s signature

Prescriber‘s name (please print)

Dose Dose
Do Not Write in this binding margin

Contact details
mg mg mg mg mg mg mg mg mg mg mg mg mg mg mg mg mg mg mg mg mg mg mg mg mg mg mg mg
Pharmacy
Prescriber Prescriber
(initials) (initials)
Comments

0800hrs 0800hrs
Nurse Nurse
(initials) (initials)
Date Medication
Clozapine
Dose Dose
Route Frequency
Prescriber to enter
Oral Evening individual doses. mg mg mg mg mg mg mg mg mg mg mg mg mg mg mg mg mg mg mg mg mg mg mg mg mg mg mg mg
Prescriber’s signature
Prescriber Prescriber
(initials) (initials)
Prescriber‘s name (please print)

2000hrs 2000hrs
Contact details Nurse Nurse
(initials) (initials)

Pharmacy

Pharmacist Pharmacist
Comments Review Review

Clozapine Titration Schedule (this table is a guide only) Dosing recommendations if clozapine dose Reason For Not Administering (codes must be circled)
If rapid or slower titration required refer to the treating psychiatrist. is missed for greater than 48 hours
In an attempt to minimise side effects the following dosing schedule is suggested: • Obtain psychiatric review prior to recommencing Absent Refused - notify Dr
clozapine.
Day 1 2 3 4 5 6 7 8 9 10 11 12 13 14
• Recommence at 12.5mg once or twice daily on the first Self Administered -
Fasting
day. If well tolerated the dose may be increased slowly observed or claimed
Morning 12.5mg 25mg 25mg 25mg 25mg 25mg 25mg 25mg 50mg 50mg 50mg 50mg 50mg 50mg
as per the Clozapine Titration Schedule.
v0.01 - 08/2012

This is a guide only - for further dosing options refer On leave Vomiting - notify Dr
Evening 25mg 25mg 50mg 75mg 100mg 100mg 100mg 125mg 125mg 125mg 150mg
to treating psychiatrist.
Not available - obtain
Titration beyond 200mg/day: If well tolerated the daily dose may be increased slowly in increments of 25–50mg. For frequency of blood testing required, refer to Blood Withheld - enter reason
supply and / or notify Dr, in clinical record
(Modified from Clozapine Titration Protocols) Test Monitoring section on page 4. consider incident report

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